Basic Information
| Provider Information | |||||||||
| NPI: | 1548232226 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YEZDANI | ||||||||
| FirstName: | KHAJA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1602 NEWPORT GAP PIKE | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198086208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026335840 | ||||||||
| FaxNumber: | 3026335844 | ||||||||
| Practice Location | |||||||||
| Address1: | 191 CHRISTIANA RD | ||||||||
| Address2: | |||||||||
| City: | NEW CASTLE | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197203024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3023221794 | ||||||||
| FaxNumber: | 3023223498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | C1-0001878 | DE | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1000015490 | 05 | DE | MEDICAID |